Discussion

Some essential adaptations to the method for determining clinically significant change originally introduced by Jacobson, Follette and Revenstorf [Jacobson, N. S., Follette, W. C. & Revenstorf, D. (1984a). Psychotherapy outcome research: methods for reporting variability and evaluating clinical significance. Behavior Therapy, 15, 336-352.] are presented. One adaptation deals with the failure in the original method to distinguish between analysis at the individual versus analysis at the group level. A second adaptation entails the provision of a closer approximation of the underlying true scores. This refinement represents an enhancement in precision. Specific aspects of this refinement may be understood in terms of a correction for error-based regression to the mean. Taking into account these adaptations, new procedures are described for determining (clinically significant) change. Some guidelines for the publication of outcome findings are also presented.     

Clinically significant but impractical? A response to Hageman and Arrindell

Hageman, and Arrindell [Hageman, W.J., & Arrindell, W.A. (in press). Establishing clinically significant change: increment of precision and the distinction between individual and group level of analysis. Behavior Research and Therapy.] suggest adaptations to the traditional clinical significance model originally developed by Jacobson, Follette, and Revenstorf [Jacobson, N.S., Follette, W.C., & Revenstorf, D. (1984). Toward a standard definition of clinically significant change. Behavior Therapy, 17, 308-311.]. They observe that one must distinguish between analysis at the individual and group level and based upon an alternative decision-making strategy have formulated different procedures for assessing clinically significant change that incorporate the unreliability inherent in testing measures. A comparison of the traditional method with Hageman and Arrindell's suggested approach is conducted utilizing data originally presented by Jacobson and Truax [Jacobson, N.S., & Truax, P., Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.] and implications of this comparison for the method developed by Hageman and Arrindell's method are discussed. Although this revised method has much to recommend it, it seems to yield results at the individual level that are quite similar to those derived from the traditional method. Given the complexity of the revised method, the traditional model developed by Jacobson, Follette, and Revenstorf (1984) still seems to be preferable.     

Clinical significance methods: a comparison of statistical techniques

Clinically significant change refers to meaningful change in individual patient functioning during psychotherapy. Following the operational definition of clinically significant change offered by Jacobson, Follette, and Revenstorf (1984), several alternatives have been proposed because they were thought to be either more accurate or more sensitive to detecting meaningful change. In this study, we compared five methods using a sample of 386 outpatients who underwent treatment in routine clinical practice. Differences were found between methods, suggesting that the statistical method used to calculate clinical significance has an effect on estimates of meaningful change. The Jacobson method (Jacobson & Truax, 1991) provided a moderate estimate of treatment effects and was recommended for use in outcome studies and research on clinically significant change, but future research is needed to validate this statistical method.     

Treatment outcome of a group cognitive therapy program for depression

A 12-session group program of cognitive therapy, designed by the first author, was evaluated with 35 persons suffering from major or minor depressive disorders. Effect-size scores were generated using the method of Nietzel, Russel, Hemmings, and Gretter (1987) and compared with cut-off points calculated using the method of Jacobson and Revenstorf (1988) and the norms established by Nietzel et al. (1987) in their meta-analysis. The effects of the Group Cognitive Therapy Program were found to be clinically significant according to the criteria of Jacobson and colleagues (Jacobson and Revenstorf, 1988; Jacobson, Follette and Revenstorf, 1984) for 73% of patients. It is concluded that the Group Cognitive Therapy Program is a clinically efficacious and cost-effective treatment for persons suffering from nonpsychotic, primary, unipolar depression.     

How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis

Controlled outcome studies investigating the efficacy of psychological treatments for obsessive-compulsive disorder (OCD) have employed different methods of determining the clinical significance of treatment effects. This makes it difficult to draw conclusions regarding the absolute and relative efficacy of psychological treatments for OCD. To address this issue, standardized Jacobson methodology for defining clinically significant change was applied to recent psychological outcome trials for OCD. The proportion of asymptomatic patients following treatment was also calculated. When recovery is defined by Jacobson methodology, exposure and response prevention (ERP) appears the most effective treatment currently available (50-60% recovered). However, when the asymptomatic criterion is used as the index of outcome, ERP and cognitive therapy have low and equivalent recovery rates (approximately 25%).     

Clinical Judgment and Clinical Significance in Psychotherapy Practice

The use of outcome measurement in psychotherapy practice is briefly discussed, as is Jacobson and Truax’s (J Consult Clin Psychol 59:12–19, 1991) conception of clinically significant change. A more flexible and user friendly application of clinically significant change compatible with clinical judgment is proposed for psychotherapy practice. Examples are given and a free Windows program is described for computing RC and estimating the probability associated with it.     

Clinically significant and practical! Enhancing precision does make a difference. Reply to McGlinchey and Jacobson, Hsu, and Speer

Based on a secondary analysis of the Jacobson and Truax [Jacobson, N.S. & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.] data using both their own traditional approach and the refined method advanced by Hageman and Arrindell [Hageman, W.J.J.M., & Arrindell, W.A. (1999). Establishing clinically significant change: increment of precision and the distinction between individual and group level of analysis. Behaviour Research and Therapy, 37, 1169-1193], McGlinchey and Jacobson [McGlinchey, J. B., & Jacobson, N. S. (1999). Clinically significant but impractical? A response to Hageman and Arrindell. Behaviour Research and Therapy, 37, 1211-1217.] reported practically identical findings on reliable and clinically significant change across the two approaches. This led McGlinchey and Jacobson to conclude that there is little practical gain in utilizing the refined method over the traditional approach. Close inspection of the data used by McGlinchey and Jacobson however revealed a serious mistake with respect to the value of the standard error of measurement that was employed in their calculations. When the proper index value was utilised, further re-analysis by the present authors disclosed clear differences (i.e. different classifications of S's) across the two approaches. Importantly, these differences followed exactly the same pattern as depicted in Table 2 in Hageman and Arrindell (1999). The theoretical advantages of the refined method, i.e. enhanced precision, appropriate distinction between analysis at the individual and group levels, and maximal comparability of findings across studies, exceed those of the traditional method. Application of the refined method may be carried out within approximately half an hour, which not only supports its practical manageability, but also challenges the suggestion of McGlinchey and Jacobson (1999) that the relevant method would be too complex (impractical) for the average scientist. The reader is offered the opportunity of obtaining an SPSS setup in the form of an ASCII text file by means of which the relevant calculations can be carried out. The ways in which the valuable commentaries by Hsu [Hsu, L. M. (1999). A comparison of three methods of identifying reliable and clinically significant client changes: commentary on Hageman and Arrindell. Behaviour Research and Therapy, 37, 1195-1202.] and Speer [Speer, D. C. (1999). What is the role of two-wave designs in clinical research? Comment on Hageman and Arrindell. Behaviour Research and Therapy, 37, 1203-1210.) contribute to a better understanding of the technical/statistical backgrounds of the traditional and refined methods were also discussed.     

Evaluation of counseling outcomes at a university counseling center: the impact of clinically significant change on problem resolution and academic functioning

The main purpose of this study was to investigate how receiving personal counseling at a university counseling center helps students deal with their personal problems and facilitates academic functioning. To that end, this study used both clinical and academic outcome measures that are relevant to the practice of counseling provided at a counseling center and its unique function in an institution of higher education. In addition, this study used the clinical significance methodology (N. S. Jacobson & P. Truax, 1991) that takes into account clients' differences in making clinically reliable and significant change. Pre-intake and post-termination surveys, including the Outcome Questionnaire (M. J. Lambert, K. Lunnen, V. Umphress, N. Hansen, & G. Burlingame, 1994), were completed by 78 clients, and the responses were analyzed using clinical significance methodology. The results revealed that those who made clinically reliable and significant change (i.e., the recovered group) reported the highest level of improvement in academic commitment to their educational goals and problem resolution, compared with those who did not make clinically significant change. The implications of the findings on practice for counseling at university counseling centers and for administrators in higher education institutions are discussed.     

Idiographic outcome analyses of the clinical significance of two interventions for patients with musculoskeletal pain

This study adopted a perspective of the individual to define domains of everyday life for the analysis of clinically meaningful change. The purpose was to compare the clinical significance of two interventions for patients with musculoskeletal pain, applying an idiographic outcome measure, The Patient Goal Priority Questionnaire, in combination with the Jacobson and Truax methodology [(1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 67 (3), 300-307] for determination of clinical significance. The concurrent validity of the outcome variables behavioral performance, satisfaction with behavioral performance, and fulfilled pre-treatment expectations was also studied. Eighty-two patients, randomized to either individually tailored behavioral medicine treatment (experimental group) or physical exercise therapy (control group) were evaluated at baseline and 3 months post-treatment regarding behavioral treatment goals. The experimental intervention had high impact on participants' performance of their highest ranked everyday life activities, and resulted in larger proportions of clinically significant outcomes compared with controls. The concurrent validity of the outcomes was high for those reporting clinically significant changes, but more generally, there was a moderate agreement across outcome categories. The individual should be the unit for analyses of clinical significance to enhance the ecological validity of the construct. Further development of idiographic outcome measures is necessary, as is the inclusion in pain intervention research.     

Assessing clinically significant change: application to the SCL-90-R

A Symptom Checklist (SCL-90-R) is a potentially useful measure of psychological distress; it is frequently used in psychotherapy research and clinical practice. The purpose of this study was to illustrate the use of the SCL-90-R for determining statistically reliable change and clinical significance outlined by Jacobson and Truax in 1991. This paper describes the concepts of statistical and clinical significance of change. A proposal for obtaining and characterizing samples is made. Then a clinician's perspective is taken. Reliable change estimates and cut-off scores are chosen based on outcome data. Selected data from a single psychotherapeutic process and outcome study then were used to test the estimates of change and cut-off scores.     

Measurement Error-Corrected Estimation of Clinically Significant Change Trajectories for Interventions Targeting Comorbid PTSD and Substance Use Disorders in OEF/OIF Veterans

In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and Relapse Prevention (RP). Eighty-one treatment-seeking veterans with a comorbid PTSD/SUD diagnosis were randomized to COPE or RP; data from an additional n = 48 patients who did not meet criteria for both disorders was used to establish a normative threshold. A newly developed, modernized approach to the Jacobson and Truax (1991) clinically significant change framework, using (a) moderated nonlinear factor analysis (MNLFA) scale scoring and (b) measurement error-corrected multilevel modeling (MEC-MLM) was used; this approach was compared to other approaches using conventional total scores and/or assuming no measurement error. Using a conventional approach to estimating the Reliable Change Index (RCI) yielded no differences between COPE and RP in the percentage of patients achieving statistically significant improvement (SSI; 88.9% for both groups). However, under MNLFA/MEC-MLM, higher percentages of patients receiving COPE (75.0%) achieved SSI compared to RP (40.7%). Findings suggest that, even though COPE and RP appear to reduce the same number of PTSD symptoms, MNLFA scoring of outcome measures gives greater weight to interventions that target and reduce “hallmark” PTSD symptoms.     

Counselling in general practice: Clients' perceptions of significant events and outcome

An investigation of clients' perceptions of the change process and outcome of counselling in primary care is presented. Significant events were identified by 51 clients post-session for a mean of 4.7 counselling sessions. Outcome was assessed by clients, through their perceptions of goal attainment and change in quality of life from pre-to post-counselling. Four-hundred-and-nine events were categorized by use of the Therapeutic Impact Content Analysis System (TICAS) and a content analysis system was created to categorize clients' goals. Results showed that ‘reassurance’, ‘problem solution ’, ‘insight’ and ‘involvement’ impacts were reported most frequently by clients. No category of significant events was related to change in quality of life. For 11 clients who set goals in the ‘expression’ category, more ‘reassurance’ and fewer ‘problem solution’ impacts were related to attainment of ‘expression’. Some suggestions are made for the lack of significant relationships with overall measures of outcome and it was suggested that more qualitative analysis of the process of outcome is needed.     

Evidence-based treatment of stuttering: II. Clinical significance of behavioral stuttering treatments

An evidence-based framework can be described as an empirically-driven, measurement-based, client-sensitive approach for selecting treatments. It is believed that using such a framework is more likely to result in a clinically significant outcome. For this paper, a clinically significant outcome was defined as a meaningful treatment change. It was suggested that there are at least three groups for whom a treatment's outcome is meaningful. These groups include clinicians/clinical researchers, the clients, and relevant others who have some interest in the outcome (e.g., parents of a child who stutters). The meaning and measurement of clinical significance was discussed for each of these three groups, based on research from the behavioral stuttering treatment literature. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) broadly define a clinically significant outcome and identify some of the groups who are interested in such an outcome and (2) describe how clinical significance has been evaluated in stuttering treatment within an evidence-based framework.     

Learned associability and associative change in human causal learning.

The Mackintosh (1975) model of associative learning specifies that processing of both the cues presented on a trial and the outcome of that trial will interact to determine the amount of associative change undergone by a given cue. Experiments looking at the distribution of associative change among the elements of a reinforced compound in animal conditioning studies indicate that processing of the outcome of a trial does indeed influence associative change. The work reported here investigates the distribution of associative change among the elements of a reinforced compound in a human causal judgement paradigm, and it indicates that processing of the cues presented on a trial also plays a role in determining associative change (in terms of changes in the associability of cues as a result of experience). Taken in combination, these results provide good support for Mackintosh (1975) and the characterizations of both cue and outcome processing that it offers.     

Anpassungsleistung und Täuschung in der forensischen Therapie

The term adaptation is often used in forensic interventions in a negative sense to describe courses of treatment without a real modification of thinking and behavior. In many cases adaptation means only a superficial problem adaptation with a risky process. This article describes and explains that in many cases adaptation can be a fundamental performance of development in a positive sense.Finally, key questions for the assessment of different adaptations and a typology of adaptations are presented. Additionally, the difference between a positive or rather desirable adaptation and deception will be defined.     

Relationships and development during adolescence: Interpersonal adaptation to individual change

Developmental perspectives on relationships address Processes of dyadic adaptation to normative changes in individuals. Relationships with parents and peers during adolescence are a microcosm of these continuous adaptations. Three key themes from research on relationships during adolescence are examined: changes in relative distance from, and connectedness to, different categories of relationship partners; the coexistence of continuity and change in relationships; and increasing differentiation and interrelation of relationships. Findings from studies of adolescent relationships (1) illustrate the potential value of normative perspectives on relationship properties and conditions and (2) underscore the need for further research on processes of relationship change. Particularly needed are testable formulations regarding the processes of relationship change and attention to interrelations among significant close relationships.     

Clinically Significant Change After Cognitive Restructuring for Adult Survivors of Childhood Sexual Abuse

This study investigated the outcome of cognitive restructuring for adult survivors of childhood sexual abuse in terms of clinically significant change. Twenty-six participants were assessed for depression, State anxiety, State anger, State guilt and self-esteem before and after 10 weekly sessions of group Rational-emotive behavior therapy, and at follow-up after 8 weeks. In contrast to a previous analysis of the data in terms of statistical significance, indicating significant improvements on all variables from pre- to posttreatment, an analysis based on clinically significant change showed a differentiated treatment effect. Cognitive restructuring was found to be highly effective in facilitating recovery on anxiety, depression and anger, but less effective for guilt and low self-esteem. Only 3 patients (11, 54%) recovered on all 5 variables, while 10 patients (38, 46%) showed recovery on at least 4 variables. Relationship to the perpetrator and pre-treatment irrational evaluative beliefs (measured by means of the Survey of Personal Beliefs) were found to be the best predictors of treatment outcome. A poor response to treatment was associated with the perpetrator being a close family member and with more Other-directed Shoulds, while recovery was associated with the perpetrator being a friend or stranger and with more Awfulizing, Self-directed Shoulds and negative Self-worth beliefs.     

Prediction of outcome in the behavioural treatment of panic disorder with agoraphobia

Outcome was predicted from pre-treatment characteristics for 62 patients with a primary diagnosis of panic disorder with agoraphobia of moderate to severe magnitude who were treated with 16 sessions of behavioural therapy. Two approaches to the task of prediction was compared: (i) predicting class membership as clinically significantly improved at post-test and at 1-year follow-up on a composite score; and (ii) predicting individual change from the same variable. Agoraphobic severity was found to be a significant predictor of clinically significant improvement at both post-treatment and follow-up. It was also found to be a significant predictor of change at post-treatment, but not at follow-up. Instead the duration of the disorder was found to be a significant predictor of change at follow-up. Perceived treatment credibility, motivation, anxious cluster personality disorder or trait anxiety were not identified as significant predictors of outcome.     

The concept of disorder as a foundation for the DSM's theory-neutral nosology: response to Follette and Houts, Part 2.

Follette and Houts [Follette, W. C., Houts, A. C. (1996). Models of scientific progress and the role of theory in taxonomy development: a case study of the DSM. Journal of Consulting and Clinical Psychology, 64, 1120-1132] argue that 'mental disorder' and 'function' are value concepts that offer no scientific basis for the DSM's theory-neutral nosology or for distinguishing disorders from other behavioral problems. They also claim that the DSM presupposes a biological theory of etiology, thus is not really theory-neutral. They recommend replacing the DSM by theory-laden diagnostic manuals. I argue: (1) DSM criteria do not imply a biological model of disorder, (2) 'mental disorder' and 'function' have scientific content that allows one to distinguish disorder from nondisorder, (3) the evolutionary 'harmful dysfunction' analysis of disorder [Wakefield, J. C. (1992a). The concept of mental disorder: on the boundary between biological facts and social values. American Psychologist, 47, 373-388] coherently demarcates disorder from nondisorder, (4) the proposed behaviorist alternative to the DSM illustrated by the articles in Follette's special section [Follette, W. C. (Ed.) (1996a). Special section on the development of theoretically coherent alternatives to the DSM system. Journal of Consulting and Clinical Psychology, 64, 1117-1201] is incoherent because it does not distinguish disorder from nondisorder.     

Vertical adaptation of the center of mass in human running on uneven ground

In running we are frequently confronted with different kinds of disturbances. Some require quick reactions and adaptations while others, like moderate changes in ground level, can be compensated passively. Monitoring the kinematics of the runner’s center of mass (CoM) in such situations can reveal what global locomotion control strategies humans use and can help to distinguish between active and passive compensation methods.In this study single and permanent upward steps of 10 cm as well as drops of the same height were used as mechanical disturbances and the adaptations in the vertical oscillation of the runners CoM were analyzed. We found that runners visually perceiving uneven ground ahead substantially adapted their CoM in preparation by lifting it about 50% of step height or lowering it by about 40% of drop height, respectively. After contact on the changed ground level different adaptations depending on the situation occur. For persisting changes the adaptation to the elevated ground is completed after the first step on the new level. For single steps part of the adaptation takes place while returning to the ground. The consistent adaptations for the different situations support the idea that controlling the CoM by adapting leg parameters is a general control principle in running.